IMPORTANT- PLEASE READ COMPLETELY BEFOREFILLING OUT DENTAL ASSISTANT PERMIT APPLICATION

THINGS TO KNOW BEFORE FILLING OUT A DENTAL ASSISTANTPERn4IT APPLICATION:

1. This is a State Permit Application and is an official state document. Lying or providingfalse or inaccurate infomation on a state document can be a criminal offense in the State

ofOklahoma. Furthermore, the Board may deny your application for providing falseinfomlatiOn, Whether it Was intentional Or not. Please read the application carefully.

2. Ifyou have a felony or misdemeanor conviction for any type ofdrug charge, regardlessofhow long ago it may have been, you may be disqualifled from obtaining a pe-it.Before you may appear before the Board, your employing dentist must first obtain a

waiver from the Oklahoma Bureau ofNarcotics (OBN) and United States DrugEnforcement Agency (DEA). No doctor or dentist that has a DEA chlg registration may

employ someone with certain types ofdrug history or they could potentially lose theirregistration.

a. The waiver must be requested by your employing dentist and may not be obtained bya corporation.

b. The waiver is only valid for the employing dentist for the specific location(s) that thewaiver was requested for. Ifyou change employers or offlce locations at any time,you must re-start this process.

3. Ifyou are on an active sentence for any type ofcriminal act (not including trafflccharges), the Board may table your application until your sentence has been resolved.

4. You must disclose any and all arrests even ifthe case was defeITed, dismissed, Orexpunged, or in another state. Our background checks WILL show any arrest even ifyoudo not have a conviction.

5. You must complete this application in full, provide a COLOR copy of your ID/DriversLicense, AND complete the 3rd page affidavit and have it notarized. Failure to submit acomplete application will delay processing and could result in your application being sentback.

6. You must apply in your LEGAL name. No nicknames, middle names, former names, orfuture names will be recognized.

7. On the 3rd page affldavit, you CANNOT flll out both affidavits. You are signing that youare either a US Citizen or a Legal Alien.

Please cohiacl the Board O ou have an uestions.

Susan Rogers, Esq.Executive Director

2017 NEW Dental Assistant Permit ApplicationFee for Permit sea.00

You must secure this Permit \^/ithin 30 days of emDIOVment in a Dental Offlce!!!

This form must be COMPLETED in full and retumed with a check or money orderto:

Oklahoma State Board of Dentistry2920 N Lincoln Bivd" Ste. B

OKC, OK 73105

'l*IF THIS APPLICATION IS NOT FILLED OuT IN FuLL ITWILL BE RETURNED BY THE BOARD

Section I. Official Reaistration and Correspondence Address"I information in Section I is required`

6iFFi6El

Name:

Daytime Phone: (

Ema" Address:

Address:

Mary FallinGovernor

State:

Date of Birth: / /

SSN:

section ll. List all office addresses in which you practice Or have Practiced in the Past year.(This includes any office in which you were employed by a dentist for any purpose. Use additional pages if necessary)

*Current Employing Dentist:

Full Time Part Time Phone: (

Addness;

*Employing Dentist:

Start Date: /

Start Date: / /

Full Time Part Time Phone: (

Address:

Section Ill. Education and Traininq

7. Are you currently a dental assistant Student in Oklahoma? Yes / No lfyes, whatschool?

2. Have you everheld expanded functlons through the State of Oklahoma? Yes / No

lf yes, what expanded funct'lons and what year did they expire?

xR- Year Expired _ CP- Year Expired _ SE- Year Expired N20- Year Expired

3. Have you everheld an Oklahoma license orpermit (ofanytype) undera Previous name? Yes / No

List previous name(s):

Section lV. You MUST answer all uestions below and si n the affidavit.

1. Have you ever been suspended from practice) reprimanded) censuredl or otherwise disciplined or disqualifled aS a Dentistl

Dental Hygienist, or Dental Assistant from any State or Licensing Jurisdiction, or are you currently under any investigation?

Yes No*I have read this question carefully and answered honestly (initial)

2. Have you ever been anested for any crlme orthe subject of ANY disciplinary action by ANY govemment, jurisdictional) or

licenslng authority; Federal, State, or Municipal/ other than speeding tickets, even if the case was deferred, dismissed/ or

expunged? Yes No*I have read this question carefully and answered honestly (initial)

3 Have you ever been convicted ofl or pled gu"ty to, or no contest to any offense related to controlled dangerous SubStanceSl a

Dull DWl, orAPC? Yes No*l have read this question carefully and answered honestly (initial)

*lf vou answered yES to ANY of the questions listed in Section IV. Please attach a letter With an explanation includin

ANY charges, dates. county/state, and the outcome.

idFailure to include this explanation may delay the Process Of your aI.PIE_eiall9n:*

Section V. Affidavit of Dental Assistant

I do hereby attest that all information or statements made on this form(s) or any Information given ln connection therewith, to be

true and correct I understand and agree that this is a State of Oklahoma official document and any misrepresentatlon orfraudulent statement on any part of this form(s) may be grounds for discipllnary action as set forth by the Oklahoma State Dental

Act as well as otherlaws underthe State of Oklahoma.

Dental Assistant Signature: Date:

Total Permit and Other Fees:1. 2017 Dental Assistant Permit (Check or Money Order Only) - $50.002. Dental Assistant lD Card ryou MUST attach a 2x2 Colored Passport Photo) - $25.00

ttID Cards are strictly voluntary. not required bv the Boardtt

*lMPORTANT:

lNCI_UDE A COLOR COPY OF YOUR DRIVERS LICENSE OR

STATE ISSUED IDENTIFICATION CARD HERE. COPY

MUST BE LEGIBLE AND PICTuRE MUST BE CLEAR OR

you WIL.I BE REQUIRED TO SUBMIT A NEW ONE.

TIIE OKLAHOMA BOARDOFDENTISTRY

Dr. James A. Sparks, Oklahoma City, PresidentDr. Lisa A. Nowlin, Elk City, OklahomaDr. Audrey Crawford, Grove, OklahomaDr. Michael Howl, Tulsa, Oklahoma

Mr. Phil Gotten, Norman, OklahomaAngela Craig, RDH, Edmond, OklahomaDr. Joseph Barrow, OKC, OklahomaDr. Curtis Bowman, Enid, Oklahoma

Dr. jeff Lunday, OKC, OklahomaMs. Lori Roberts, Esq., Tulsa, OklahomaDr. Jim Gore, Pryor, Oklahoma

Please note You CIANNOT fill out br)th affidavits. AW natural persons fourteen (14) )rears of age or older and present in the United Statesapplying for a license with the Oklahoma Board of Dentistry are required by the provisions of 56 O.S. Supp. 22O7 § 71, to provide the Board whh verificationof la\^rful presence in the United States by executing on of the Affidavits below before Notary PtJbliC or Other Officer atJthOriZed to notarize Affidavits Llnder

State law. The Board's licensing offices are staffed with notaries who are available to provide notary service at no cost to applicants.

Ootion1- Verification of Citizenship

Affidavit of:

(Applicant's Name)

STATE OF:

COUNTY OF:

perjury, as follows:

Subscribed and sworn to or afflrmed before me this

of lawful age, being duly sworn, upon oath states, under penalty of

I am a United States Citizen.

(Signature of Applicant)

(SEAL)

(Applicant)

(Notary)

STATE OF:

My Commission Expires:

Option 2- Verifying Qualified Alien Status - Please submit a copy of your passport, green card, eta. with this application!

Affidavit of:

(Applicant's Name)

COUNTY OF:

of lawful age, being duly sworn, upon oath states, under penalty of

perjury' as follows: I am a qualified alien under Federal lmmiaration and Naturalization Act. and I am lawfully present in the United States.

(Signature of Applicant)

Subscribed and swam to or affirmed before me this

(Applicant)

(Notary)

My Commission Expires:

(SEAL)